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f .2 3 4 5 10 11 12 13 14 15 16 17 18 19 20 21 22 23 2 4 'ede.al Reporters, Inc. n 1 DEPARTMENT OF HEALTH, EDUCATION, AND L7ELFARE :, . JESSEE L. STEINFELD, M.D. Surgeon General of the U. S. Public Health Service DANIEL HORN, M."D. '- Director National Clearinghouse for Smoking and Health Room 5051 North HEW IIu3lding '' Washington,.D:C. 0 24'798 TIMN 0113384 ~; Tsas0s3 25

! ~ 1 2 3 4 5 6 7 8 9 10 11 12 2 P R 0 C E E D I N G 5 DR. STEINFELD: Good morning. With me this morning is Dr. Daniel Horn, Director of the National Clearinghouse on Smoking and Health. Fle and I will attempt to answer any questions you may have after I present'a short opening statement. ..Research on smoking and health over the past year has confirmed and strengthened previous findings regarding . . •t, the significance of cigarette smoking as one of the Nation's most serious public health problems. The number of deaths in the U. S. clearly related to cigarette smoking is far in excess of those caused by epidemics of poliomyelitis, cholera, typhus, or similar infectious diseases. - But the measures previously.taken to combat cigarett4 17 18 19 smoking by citizens and government alike fall far short of• the measures taken by society to protect itself against communicable diseases. Of course, the difference is that cigarette-smoking is largely a personal thing whereby the cigarette smoker harms_only himself (if one assumes the non-smoker does not have equal rights, and is not subject to any harm from his cigarette-smokirig'neighbor) .'I'IlVIN 0113385 Our society has been most successfull in combatting 24 "e~aral Reporters, Inc. 25 public health problems when the citizen has been passive• T11 That is, we have purified our water supplies, we've prevented 064

. r ~ I ~ 1 2 3 5 6 7 8 •9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 `•:_'•?tal Reporters, ine. 25 3 sewage from entering our drinking water, we've pasteurized milk, made certain that meat products did not transmit trichinosis, brucellosis, and tuberculosis, and we've immunized our citizens after researchers developed vaccines against smallpox, polio, measles, and the like. But we have not been successful when the citizen had to take an active and continuing and responsible role: when he must exercise, when•hp, must choose foods to avoid obesity and arteriosclero-. sis, when he must restrict his' alcohol•intake and when he must restrict or eliminate smoking of cigarettes. Ourr failures have been when we require an active role on the part of our citizens. • Now,'iehat is the proper role for Government in a free society? Is it to protect citizens from harming themselve~-? . ,# If so, and if by January 10, 1972, we have determined Govern- f ment's prop er.•• role, it is far from being successful in that cigarette smoking and disease from cigarette smoking continue in our society. On the positive side, 29 million Americans have ~ stopped•smoking. But on the negative, 44 million Americans continue to sm9ke. In the final analysis, education and en- ® ~ lightened self-interest should result in a non=smoking society, ~ 4•Ihile,I am clearly dissatisfied with the.success W 00 of our efforts to date, I do want to emphasize th at without T115 65 the concerted governmental and citizen campaigns which"have

. ~ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 . 15 16 17 18 19 20 21 22 23 24 4 been mounted over the last seven years, we could have a Nation of perhaps 75 million smokers and many more deaths due to cigarette smoking: SJhen I reviewed this report last weekend, I also read a newspaper account of what happened to cigarette con- sumption in the United States in 1971. I have since learned' that the newspaper account was somewhat more flattering to the sales efforts of the cigarette industry than the facts , „ . . warrant, but the facts are still bad enough. . Sales of cigarettes in 1971 increased by one.and a half percent, and while this represents'no increase in per capita consumption, because our adult population increased in 1971 by the same amount, it represents certainly no drop in cigarette consumption. At the moment, we are at a stalemate. I hope that in the next year, each American citizen will review for himself the summary findings of what is no , longer an honest disagreement among*medical scientists about the hazards'of cigarette smoking. There is no disagreement-- cigarette smoking is deadly. For a full review of our current knowledge, I refer you to the report before you. TIMN 0113387 ~ I would like to emphasize four points in the report which reinforce previous data, and I the three new chapters very briefly. would like to mention ~:~•:ral Reporters, Inc. F irst and most important, because it affects -the

5 5 1 2 3 4 5 6 7 8 9 10 unborn, it has been shown in two prospective studies in Sweden, designed specifically for this purpose, that pregnant women who smoke have a higher incidence of abortions, and pregnant women who smoke have a higher number of stillborn babies; babies who die within the first few days or weeks of life, and babies who die within one year of birth. This is not a small number of excess deaths. There is a.t least a third excess deaths among smoking pregnant women as compared to non-smoking pregnant women. Secondly, in the area of coronary heart disease,. the data continue. to accumulate which shows'that cigarette smoking is a major risk factor and contributes to the develop- ment of coronary heart disease. Thirdly, and very important, in a'very large 15 16 17 18 19 20 21 22 23 24 ~=ra1 ~eportr.rs, Inc. 25 Japanese prospective study to determine incidence of disease and death associated with cigarette smoking, thp findings largely confirm those of previous American studies, and previous Western civilization studies. These data are important not only because in Japan we have a difference genetic, cultural'group, a group with different diet,, different mores, but because rather than having a self-selected population for a prospective study, a factor which has been criticized in our previous prospective T 1150 studies, approximately ninety-five percent of the citizens of selected portions of Japan 4rere followed in this p-rospective 67

, „ 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 -l 8 19 20 21 22 23 2 4 :1da+al Repor,ers, Ine. study. This is very significant, because this study similarly shows a quantitative relationship between cigarette smoking . and lung cancer. The more the citizens of Japan smoke cigarettes, the higher their incidence of lung cancer. And finally, in areas wherein we have had previous data, when high.schooZ-students smoke cigarettes, they have more,.symptoms of pulmonary function which is impaired as.. .. compared with non-smoking high• school students. So cigarette smoking does not take twenty or thirty years to exact its toll. it may take that long before death occurs, but symptoms of impaired pulmonary.function are found as early as in the high school years. Now finally, the three new chapters. We have a chapter on allergy, which shows not only do the constituents of cigarette smoke act as allergents, but there is a non- specific effect of cigarette smoke in exacerbating the allergie of individuals who are allergic to a wide variety of substan- ces; particularly this is true among children,who do not smoke Secondly, there is a chapte•r on the effect of cigarette smoking on the non-smoker, the so-called passive . And here we find it is extremely significant cigarette smoker. that levels of carbon monoxide, which wz-previously had not associated with harm and previously did not associate'wi , tT115p68 25 ~~ the development s,rmptontatology, we find that the non-srttoker

7 1 2 is exposed to levels of carbon monoxide and develops carboxy-. hemoglobin within his own system, to the extent that it can impair visual acuity, auditory -- hearing, that is -- and ability to drive. The levels of .'carboxyhemoglobin developing in 7 8 14 18 19 20 21 221 1 23! smoke-filled rooms and automobiles are indeed significant, and of course all of our animal experiments showing effects on the.pul,monary system, that is, emphysema and chronic dy.splasia, and ultimately cancers;.all of these findings are 'similar to that of the non-smoker, because the-animals exposed to cigarette smoke inhaled..it passively, and this .is similar to that of the non-smoker exposed to the smoke by his cigarette-smoking neighbors. Finally, there is a chapter on the harmful constituents of tobacco. We have identified these in a number of ways. In addition to tar and nicotine, about which much has been written over the years, we include among the prime harmful constituents now carborl monoxide. And if one is to take action, it certainly'should be agains't those ingredients of cigarette smoke which we have identified as contj:ibuting to a.health hazard. These_would be, then, tar, nicotine, and carbon monoxide. And in our studies, the carbon monoxide levels seem to parallel that of the -tar level within the cigarette. TIMN 0113390 T11 5 S•;nat that all adds up to is the fact that this last 69

8 ~ 1 2 3 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 year we continued to accumulate scientific data indicting cigarette smoking as a major public health hazard. We are' far from having contained the problem in the United States. Now Dr. Horn and I would be pleased to try to answer any questions you may have. QUESTION: Dr. Steinfeld, in the report, the report makes extensive mention of the effect of carbon monoxide on'non-smokers, people who are in the same room with smokers. ~. . And expecially persons who suffer from lung and heart disease. Are there any indications that the cancer-producing agents that-are contained -- the cancer-causing agents that are contained in tar also have an effect on the non-smokers? DR. STEINFELD: The question is, there is consider- able space devoted to the effects of carbon monoxide affecting non-smokers -- carbon monoxide produced by cigarette smoke. What is the effect of the carcinogenic• 'hydrocarbons and other carcinogenic materials in cigarettes upon the non- smoker? I tried to answer this in a left-handed way because it would be very difficult to do any kind of humari experiment.--in fact, I hope we never do such experiments , by pointing out that animals exposed passively to cigarette smoke do develop the changes, and in certain species what would be construed as neo-pzasms, although not the type produced in man. TIMN 0113391 Tii5070

9 a. 1 2 3 4 5 7 8 10 11 12 13 14 . 15 16 17 18 19 20 21 22 23 24 Rcportcrs, Inc. 25 So this would be the closest we could come to the human experiment, that is, by using animal experiments. Of course, the length of time for the development of a neo-. plasm is much unlike that for the development of carboxy- hemoglobin, which occurs rapidly. Carbon monoxide has some- thing like ten times the affinity and medically, carbon monoxid will attach to hemoglobin remains for a long time. ;, The kind of experiment one needs for the carcino- gensis study would be longterm. . QUESTION: A follow-up on that question. Since the report does contain new findings on the harmful effects on the non-smoker, do I detect a conflict? Because you say in prepared statement that the cigarette smoker'harms only himself.- DR. STEINFELD: No. I said in the statement that the cigarette smoker primarily affects himself, if one assumes the non-smoker does not have equal rights, and if he is not harmed by his cigarette-smoking neighbor, which I added. QUESTION: Dr. Steinfeld, did I- understand you to say that•the carbon monoxide danger is in your mind equal to the*tar danger?. TIMN 0113392 , ti ' DR. STEINFELD: No, I didn't say it is equal to the . T115 '71 tar danger. I said it is easier to measure the carbon mono;d.de concentration in a room, and easier to measure the carboxyheMoglobin levels in the smo.;er and non-smokers having your IL .

have earlier about exposure of the non-smoker to these carcinogenic hydrocarbons becomes significant. I would add, of course, that we are exposed to the 10 1 the higher level, and we know in terms of occupational studies 2 and other studies what levels of carboxyhemoglobin may impair 3 whether the visual, audi- various kinds of human performance , :: 4 tory, the ability to reason, or the ability to manipulate 5 things. 6 It is much more difficult of course to quantitate 7 the tar levels or to determine whether or not there is a 8 threshhold in terms of carciogenesis. All of our data in terms 9 of chemical carcinogenesis would indicate there is no ' 10 threshhold and therefore the questions,questions that we. 14 15 16 17 18 19 20 21 22 23 241 =1 R^_potters, Inr,. I 25 + exhaust of automobiles and to a number-of carcinogenic • • hydrocarbons in-our environment. •QUESTION: Dr. Steinfeld, is this the reason that you didn't make a flat condemnation of the effects.of smoking on non-smokers, as you did of smoking on sniokers? DR. STEIrIFELD: Oh, well, I would make a flat condemnation of the effect of smokers on non-smokers, but we can't quantitate, it in terms of carcinogenic hydrocarbons. W7e can in terms of carbon monoxide, in places which are , . . _ '-- - . , .. . . . . . not well ventilated. we can in terms of allergic individuals who get a:zon-specific response to the allergens contained t•i9.Lhin c;igarette s:ijo,ce, and in terms of discomfort and irri- 72